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          <h1 class="post-title" itemprop="name headline">年轻恒牙外伤折断的处理</h1>
        

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        <p>昨天刚接了个年轻中切牙外伤露髓的患者，处理我知道，但是做得不多，正好查一些资料。也分享给大家。参考《McDonald and Avery’s Dentistry for the Child and Adolescent》第27章，”Management of Trauma to the Teeth and Supporting Tissues”。<br>诊断外伤的范围很困难。牙外伤后不可避免伴有牙髓充血，其范围很难确定。牙髓血运的改变有可能导致牙髓坏死。根尖血管也有可能受损而影响组织修复过程。治疗或外伤导致的牙髓暴露或牙齿脱位很有挑战性，因为预后是不确定的。<br>折裂牙的处理，尤其对于年轻患者，更复杂。牙医由于牙髓预后的不确定性常推迟进行修复。但由于失去正常的接触关系常导致错颌畸形。邻牙移位常给最终修复带来困难。<br>治疗的成功率常取决于外伤与处理之间的时间间隔。国际牙外伤协会报告约有一半的儿童会经历牙外伤，最常发生在8-12岁之间。一个迅速和恰当的处理可以减少牙外伤对口腔功能和美学的影响。<br>该组织出了个牙外伤治疗指南，有中文的（链接见文末）。先看看这个指南。<br>乳牙外伤最常见的类型是半脱位，恒牙外伤多见于冠折。幼儿牙外伤就诊时，要特别注意受伤乳牙的根尖与继承恒牙胚之间的关系。年轻恒牙外伤，首选的治疗方案是尽量保存其牙髓，以确保年轻恒牙牙根的继续发育。当年轻恒牙发生折断暴露牙髓时，或发生脱位性损伤或根折时，牙髓都具有较强的修复能力。撕脱恒牙的预后在很大程度上取决于在事故发生地对外伤牙的即刻处理。<br>乳牙外伤的复诊时间：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0225-waishang/01.png"><br>大多数是1周，2月，1年复诊。<br>恒牙外伤的复诊时间：<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0225-waishang/02.png"><br>多数是1月，2月，3月，半年，1年复诊。<br>牙髓活力测试对于暂时性神经反应丧失的年轻恒牙可能不准确。每次随访均需进行活力测试。不推荐使用广谱抗生素。每次随访复诊除了询问病人的体征或症状外，还应进行临床检查和影像学检查、以及牙髓活力测试。强烈推荐拍摄病人外伤的临床照片并记录病历。主要并发症有：牙髓坏死和感染、根管闭锁、多种类型的牙根吸收、牙龈缘退缩和牙槽嵴顶吸收。<br>对于年轻恒牙，保存牙髓可以促进牙根的继续发育和根尖孔的形成。当年轻恒牙发生复杂冠折、脱位损伤或根折时，暴露的牙髓具有强大的愈合能力，应选择直接盖髓术、部分活髓切断术和颈髓切断术等保存活髓的治疗方法(不固化的氢氧化钙或不染色的硅酸盐水门汀是较为合适盖牙髓的材料），以维持牙根的继续发育。即使年轻恒牙的牙髓发生感染坏死，也可选择牙髓血管再生治疗，如牙髓血运重建。<br>当成年恒牙发生严重的复合型外伤时，医生可预判会发生牙髓坏死和感染，可进行预防性根管治疗。<br>根管闭锁症(PCO）经常出现在根尖孔开放的年轻恒牙发生严重脱位性损伤时，这种现象通常表明外伤后的年轻恒牙根管内牙髓仍然保存活力。<br>发育成熟的恒牙在外伤后牙髓仍有可能存活，但发生嵌入性脱位、严重的脱出性脱位或侧方脱位时，牙髓几乎没有存活，通常建议早期进行根管治疗。在牙外伤后1-2周，推荐使用氢氧化钙进行根管内封药1个月，然后进行根管充填。皮质类固醇或抗生素糊剂可以用作抗感染和抗吸收的根管封药，来控制感染性根外吸收，应在牙齿外伤复位后立即放置这种糊剂于根管内，直至观察6周，应避免糊剂放入腔壁，因为糊剂可能导致牙冠变色。<br>根尖孔开放的年轻恒牙：只有在复查中出现临床症状和影像学证据，显示牙髓坏死或根尖周感染，才能进行根管治疗。医生应权衡外伤牙发生感染性牙根吸收的风险与牙髓血运重建的可能性，一旦年轻恒牙发生根吸收进展迅速。因此，要强制患者定期复诊检查，一旦发现外伤牙的感染性根吸收，应立即进行根管治疗。年轻恒牙嵌入性脱位并冠折时，其牙髓坏死和感染的风险较高，可以考虑立即或早期进行根管治疗。对于年轻恒牙的牙髓坏死，还可进行根尖诱导成形术或牙髓血运重建/牙髓再生术。在没有完整的断冠可以粘接的情况下，暴露的牙本质断面应用玻璃离子覆盖或使用粘接剂及复合树脂充填。<br>一旦发现外伤牙出现感染性牙根外吸收迹象，应立即进行根管治疗，根管内用氢氧化钙制剂进行封药。放置氢氧化钙3周，每3个月更换一次，直到吸收性病变的透射影区消失。当X线片上可见骨修复形成时，可进行最终的根管充填。<br>(以上参考：Liran Levin,Peter Day,Lamar Hicks,et al.国际牙外伤协会（IADT）牙外伤治疗指南(2020版))<br>再回到教科书。<br>牙外伤牙髓暴露的处理。<br>1.直接盖髓：外伤1-2小时内，牙髓暴露较小，剩余牙冠组织能支持盖髓剂。如果最终修复需要根管桩或髓腔固位，那么活髓切断术或牙髓摘除术也是治疗的可选方案。将断面清理干净，在放置盖髓剂以前，牙髓需保持湿润。盖髓要求是隔绝口腔内液体。因此在放置了盖髓剂以后应该立即进行牙体修复。覆盖活髓的牙本质样材料应该覆盖活髓组织至少2个月。如果适应症选择合适，操作正确，牙髓会保持功能，牙本质继续发育，使得可以保持牙髓活力而进行牙体修复。<br>2.牙髓切断术（Pulpotomy）：牙髓因外伤暴露，根尖孔未发育未完成（开放根尖孔），或者虽然髓腔暴露很小但是患者就诊时间距外伤数小时甚至数天后，或者冠部没有足够牙体支持盖髓剂的情况。或者外伤发生在成熟恒牙（根尖孔闭合），导致髓腔暴露和根折的情况。要保守地扩大髓腔暴露位点，在橡皮障下移除冠部1-2mm的牙髓组织，或按照传统的做法去除所有冠部牙髓组织。当切除牙髓达到预想的程度后，用大量的冲洗液彻底清洗髓腔。不要存留肉眼可见的牙本质碎片或牙髓组织。如果剩余的牙髓是健康的，用湿棉球按压组织可以容易的控制出血。牙髓应该有一个亮的粉红色和一个凹陷的轮廓(半月形）。如果牙髓的健康状况有疑问，需要切除更深的牙髓。将氢氧化钙轻柔的放置在牙髓组织上，使其与牙髓组织被动接触。在其上用硬固的(Hard-setting)，生物相容性和边缘封闭性能良好的材料封闭。冠方用独立的粘接过程修复。一些专家建议一旦根尖孔闭合，立即进行根管治疗。他们将氢氧化钙视为一种为达到牙根发育根尖孔闭合而采取的临时措施。他们认为活髓切断和根尖闭合后的根管充填是防止过度钙化反应导致的根尖闭锁。然而，在活髓切断术后的长期成功可以发生在没有钙化变性的情况下。如果髓腔内仍有健康牙髓，如果冠髓被彻底去除并没有多余的损伤，如果氢氧化钙被轻柔的放到断髓的地方与牙髓组织接触，没有施加压力，如果牙齿被良好的封闭，长期成功的而不需根管治疗的可能性很大。<br>3.活髓切断术加根管治疗：开放根尖孔的治疗和根充是一个很大的挑战。这样的年轻恒牙在根尖区域髓腔最大，而在冠部区域最小。不通过根尖手术而严密封闭根尖区域常常不可能。这种根尖外科手术对于年轻患儿来说常常有很大创伤，应该尽量避免。成功的活髓切断术允许根管内的牙髓保持活髓状态，根尖能继续发育。对于复杂的折裂，修复也许需要根管桩的支持，在这样的修复完成前，可以进行常规的根管治疗。有时外伤患牙有急性根尖脓肿，这时就需要在一个开放根尖孔的患牙上进行根管治疗。如果存在脓肿，必须首先处理。如果有急性疼痛和软组织肿胀的迹象，通畅整个根管能迅速缓解患儿症状。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0225-waishang/03.png"></p>
<p>参考文献：<br><font size=1>1.Jeffrey Dean.McDonald and Avery’s Dentistry for the Child and Adolescent 10th Edition.22nd September 2015.<br>2.Liran Levin,Peter Day,Lamar Hicks,et al.国际牙外伤协会（IADT）牙外伤治疗指南(2020版). <a target="_blank" rel="noopener" href="https://www.iadt-dentaltrauma.org/images/Chinese_IADT-Guidelines_FULL2020.pdf">https://www.iadt-dentaltrauma.org/images/Chinese_IADT-Guidelines_FULL2020.pdf</a></font></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的知乎文章地址： <a target="_blank" rel="noopener" href="https://www.zhihu.com/people/zhao-you-min/posts">https://www.zhihu.com/people/zhao-you-min/posts</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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